| Certificate Number | 36 | | Date Issued |
| Child Given Name | Dwight Elmo |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Nov 1887 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Joseph |
Johnson | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Ohio | 40 | Father's Age |
| Mother's Given Name | Isabel | Patten | Mother's Maiden Name |
| Mother's Surname | Johnson | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 38 | 2 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |